<h3 id="caption_title">Birth Certificate Request Form</h3>

<form method="post" action="submit.php" id="form" name="form">
    <a href="#" id="show_data" class="float-right">Show Data</a>
    <table class="table table-condensed border-right"> 
       <tbody>
           <tr>
               <td>Province:</td>
               <td><input type="text" class="span3"  id="province" name="province"></td>
               <td></td>
           </tr>
           <tr>
               <td>City/Municipality:</td>
               <td><input type="text" class="span3" id="city_municipality" name="city_municipality"></td>
               <td></td>
           </tr>
           <tr>
               <td><strong>Name</strong></td>
               <td></td>
               <td></td>
           </tr>
           <tr>
               <td><input type="text" class="span3" id="first_name" name="first_name">
                   <br>First Name</td>
               <td><input type="text" class="span3" id="middle_name" name="middle_name">
                   <br>Middle Name</td>
               <td><input type="text" class="span3" id="last_name" name="last_name">
                   <br>Last Name</td>
           </tr>
           <tr>
               <td><strong>Sex</strong></td>
               <td></td>
               <td></td>
           </tr>
           <tr>
               <td><input type="radio" class="span1" value="Male" checked id="sex" name="sex">
                   Male</td>
               <td><input type="radio" class="span1" value="Female" id="sex" name="sex">
                   Female</td>
               <td></td>
           </tr>
           <tr>
               <td><strong>Date of Birth</strong></td>
               <td></td>
               <td></td>
           </tr>
           <tr>
               <td><select class="span1" id="day" name="day">
               <?php
               
                   $i = 1;
                   for($i = 1; $i <= 31; $i++)
                   {
                       echo "<option value='$i'>$i</option>";
                   }
               
               ?>
                   </select>
                   <br>Day</td>
               <td><select class="span2" id="month" name="month">
               <?php
               
                   $i = 1;
                   for($i = 1; $i <= 12; $i++)
                   {
                       echo "<option value='".date("F", mktime(0, 0, 0, $i, 1, 0))."'>"
                           .date("F", mktime(0, 0, 0, $i, 1, 0))
                           ."</option>";
                   }
               
               ?>
               </select>
                   <br>Month</td>
               <td><select class="span2" id="year" name="year">
               <?php
               
                   $i = 2012;
                   for($i = 2012; $i >= 1900; $i--)
                   {
                       echo "<option value='$i'>"
                           .$i
                           ."</option>";
                   }
               
               ?>
               </select>
                   <br>Year</td>
           </tr>
           <tr>
               <td><strong>Place of Birth</strong></td>
               <td></td>
               <td></td>
           </tr>
           <tr>
               <td><input type="text" class="span3" id="hospital_street" name="hospital_street">
                   <br><small>Name of Hospital/Institution; if not in hospital, give street/barangay</small></td>
               <td><input type="text" class="span3" id="p_city_municipality" name="p_city_municipality">
                   <br>City/Municipality</td>
               <td><input type="text" class="span3" id="p_province" name="p_province">
                   <br>Province</td>
           </tr>
           <tr>
               <td><strong>Type of Birth</strong></td>
               <td></td>
               <td></td>
           </tr>
            <tr>
               <td><select class="span3" id="type_of_birth" name="type_of_birth">
                       <option value="Single">Single</option>
                       <option value="Twin">Twin</option>
                       <option value="Multiple">Multiple</option>
                   </select>
                   </td>
               <td></td>
               <td></td>
           </tr>
           <tr>
               <td><strong>Mother's Name</strong></td>
               <td></td>
               <td></td>
           </tr>
           <tr>
               <td><input type="text" class="span3" id="m_first_name" name="m_first_name">
                   <br>First Name</td>
               <td><input type="text" class="span3" id="m_middle_name" name="m_middle_name">
                   <br>Middle Name</td>
               <td><input type="text" class="span3" id="m_last_name" name="m_last_name">
                   <br>Last Name</td>
           </tr>
           <tr>
               <td><input type="text" class="span3" id="m_nationality" name="m_nationality">
                   <br>Nationality</td>
               <td><input type="text" class="span3" id="m_religion" name="m_religion">
                   <br>Religion</td>
               <td></td>
           </tr>
           <tr>
               <td><strong>Father's Name</strong></td>
               <td></td>
               <td></td>
           </tr>
           <tr>
               <td><input type="text" class="span3" id="f_first_name" name="f_first_name">
                   <br>First Name</td>
               <td><input type="text" class="span3" id="f_middle_name" name="f_middle_name">
                   <br>Middle Name</td>
               <td><input type="text" class="span3" id="f_last_name" name="f_last_name">
                   <br>Last Name</td>
           </tr>
           <tr>
               <td><input type="text" class="span3" id="f_nationality" name="f_nationality">
                   <br>Nationality</td>
               <td><input type="text" class="span3" id="f_religion" name="f_religion">
                   <br>Religion</td>
               <td></td>
           </tr>
           <tr>
               <td></td>
               <td><div id="s"></div></td>
               <td class="">
                    <input type="button" class="btn btn-blue float-left span2" id="reg" value="Sumbit">
                    <input type="reset" class="btn btn-green float-right" value="Clear">
               </td>
             
           </tr>
       </tbody>
    </table>
</form>